Disease increased after radiation?

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crybaby
Posts: 18
Joined: Sat Jun 11, 2022 4:20 am

Disease increased after radiation?

Postby crybaby » Tue Jun 21, 2022 3:55 am

So my dad went 25 fractions of radiation (45 Gy) for pelvic radiation and sacral met which he finished on 11 May, 2022. Last PET scan was done in Mar 2022 and the recent PET scan was just done yesterday in (June 2022).

ill defined soft tissue lesion in pelvic cavity (SUVmax 8.54 vs 8.16, 46x43 vs 45x41 mm). It was SUVmax 7.78 pre-radiation and size was 2.3x3.1cm. It also says lesion is inseparable from adjacent bowel loops. Significant perlesional fat and stranding nodularity is seen.
Negligible FDG avid few small subcentimetric reptroperitoneal, abdominal and pelvic lymph nodes are seen. No size significant FDG avid lymphadenopathy in abdominal and pelvic region.

And the sacral lesion has also gone from SUVmax 8.8 to 9.99. It says "intense FDG avid predominantly sclerotic osseous lesion in proximal body of sacrum at S1 vertebra.

Though post radiation(1 month after treatment) CEA has dropped to 1.98 which was about 4.8 (pre-treatment).

Our doc pre-treatment told us that the radiation will just eradicate these mets and if somehow they lived they will get too small then the chemo can finish them off. I have no idea what to do now.

What should be my next step?

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Peregrine
Posts: 100
Joined: Tue Mar 01, 2022 1:18 am

Re: Disease increased after radiation?

Postby Peregrine » Tue Jun 21, 2022 9:11 am

crybaby wrote:So my dad went 25 fractions of radiation (45 Gy) for pelvic radiation and sacral met which he finished on 11 May, 2022. Last PET scan was done in Mar 2022 and the recent PET scan was just done yesterday in (June 2022).

ill defined soft tissue lesion in pelvic cavity (SUVmax 8.54 vs 8.16, 46x43 vs 45x41 mm). It was SUVmax 7.78 pre-radiation and size was 2.3x3.1cm. It also says lesion is inseparable from adjacent bowel loops. Significant perlesional fat and stranding nodularity is seen.
Negligible FDG avid few small subcentimetric reptroperitoneal, abdominal and pelvic lymph nodes are seen. No size significant FDG avid lymphadenopathy in abdominal and pelvic region.

And the sacral lesion has also gone from SUVmax 8.8 to 9.99. It says "intense FDG avid predominantly sclerotic osseous lesion in proximal body of sacrum at S1 vertebra.

Though post radiation(1 month after treatment) CEA has dropped to 1.98 which was about 4.8 (pre-treatment).

Our doc pre-treatment told us that the radiation will just eradicate these mets and if somehow they lived they will get too small then the chemo can finish them off. I have no idea what to do now.

What should be my next step?

I'm very sorry to hear about the increases in size and SUV-uptake in your dad's post-radiation PET-CT scan. It's certainly discouraging to hear this, and I don't know quite what to say. Maybe the scan was done too early after radiation and was still picking up signals from inflammation caused by the radiation itself:
    Research Cautions On False Positives For Cancer With PET Scans
    "However, not all PET-positive lesions are cancer, and in many instances, PET findings can be false positive."
    .
    "...Inflammatory cells also have increased metabolic rates and, as a result, are FDG avid….

    "...When seeing a new focus of FDG uptake, before informing the patient that the lesion is cancer, the surgeon and oncologist must determine whether this is truly a cancer or a possible false-positive finding...

    Reference: https://cancer.stonybrookmedicine.edu/falsepositives

For now, what I think you should do is to try to put this out of your mind for a few days so that you can concentrate on studying for your exam. Then after your exam you could do some reading on false positives on PET-CT scans.

I myself have had some experience with PET-CT false positives. When I was still under treatment, one of my scans showed my left tonsil enlarged, with significant SUV-uptake. The doctor said he was convinced that I had a malignancy in my tonsil. I tried to explain to him that this was probably not the case. I explained that I always sleep on my left side and that my sinuses drain onto my left tonsil, and during allergy season I frequently observe that my left tonsil is much larger than my right tonsil. He wouldn't believe a word of what I was saying, and as a result he scheduled me for a series of costly exams that showed, eventually, that it wasn't cancer after all.

So, I have become rather cynical and skeptical about radiologists' ability to interpret scans correctly, especially when the radiologists are new and inexperienced.

Good luck on your exams !!

Rock_Robster
Posts: 694
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Disease increased after radiation?

Postby Rock_Robster » Wed Jun 22, 2022 3:36 am

Sorry to hear the news. Of course it would have been great to see regression of disease across the board. I have two general thoughts here, not sure if very useful:

1. I had been told that a PET within 2 months of surgery or radiation is not particularly useful, due to the high levels of inflammation and post-treatment changes in the tissue. I just had a PET this week 2 months after radiation (and 3 months after surgery), and it was still quite tricky to interpret. Did anyone discuss this aspect with you? Did they also do a diagnostic CT on both scans that could perhaps be used to accurately measure tumor volume (rather than SUVmax activity levels)?

2. If the previous PET was in March and the treatment in May, is it possible that this progression occurred in the period prior to the radiotherapy? So this may in fact not be post-treatment progression, but progression since March and the treatment effects have not yet been seen.
40M Australia
2018 Dx RC, 12cm high
G2, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then <2. Jun-22: 5
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo (reversed)
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
11/21 Liver met & celiac node; 2-3 tiny lung things
12/21 PVE
3/22 Nodal spread & 3 liver mets. Lymphadenectomy
4/22 Liver SBRT
6/22 Liver looks good. Still some small lung things

crybaby
Posts: 18
Joined: Sat Jun 11, 2022 4:20 am

Re: Disease increased after radiation?

Postby crybaby » Wed Jun 22, 2022 4:25 am

Peregrine wrote:
crybaby wrote:So my dad went 25 fractions of radiation (45 Gy) for pelvic radiation and sacral met which he finished on 11 May, 2022. Last PET scan was done in Mar 2022 and the recent PET scan was just done yesterday in (June 2022).

ill defined soft tissue lesion in pelvic cavity (SUVmax 8.54 vs 8.16, 46x43 vs 45x41 mm). It was SUVmax 7.78 pre-radiation and size was 2.3x3.1cm. It also says lesion is inseparable from adjacent bowel loops. Significant perlesional fat and stranding nodularity is seen.
Negligible FDG avid few small subcentimetric reptroperitoneal, abdominal and pelvic lymph nodes are seen. No size significant FDG avid lymphadenopathy in abdominal and pelvic region.

And the sacral lesion has also gone from SUVmax 8.8 to 9.99. It says "intense FDG avid predominantly sclerotic osseous lesion in proximal body of sacrum at S1 vertebra.

Though post radiation(1 month after treatment) CEA has dropped to 1.98 which was about 4.8 (pre-treatment).

Our doc pre-treatment told us that the radiation will just eradicate these mets and if somehow they lived they will get too small then the chemo can finish them off. I have no idea what to do now.

What should be my next step?

I'm very sorry to hear about the increases in size and SUV-uptake in your dad's post-radiation PET-CT scan. It's certainly discouraging to hear this, and I don't know quite what to say. Maybe the scan was done too early after radiation and was still picking up signals from inflammation caused by the radiation itself:
    Research Cautions On False Positives For Cancer With PET Scans
    "However, not all PET-positive lesions are cancer, and in many instances, PET findings can be false positive."
    .
    "...Inflammatory cells also have increased metabolic rates and, as a result, are FDG avid….

    "...When seeing a new focus of FDG uptake, before informing the patient that the lesion is cancer, the surgeon and oncologist must determine whether this is truly a cancer or a possible false-positive finding...

    Reference: https://cancer.stonybrookmedicine.edu/falsepositives

For now, what I think you should do is to try to put this out of your mind for a few days so that you can concentrate on studying for your exam. Then after your exam you could do some reading on false positives on PET-CT scans.

I myself have had some experience with PET-CT false positives. When I was still under treatment, one of my scans showed my left tonsil enlarged, with significant SUV-uptake. The doctor said he was convinced that I had a malignancy in my tonsil. I tried to explain to him that this was probably not the case. I explained that I always sleep on my left side and that my sinuses drain onto my left tonsil, and during allergy season I frequently observe that my left tonsil is much larger than my right tonsil. He wouldn't believe a word of what I was saying, and as a result he scheduled me for a series of costly exams that showed, eventually, that it wasn't cancer after all.

So, I have become rather cynical and skeptical about radiologists' ability to interpret scans correctly, especially when the radiologists are new and inexperienced.

Good luck on your exams !!

Hi, I really appreciate your wishes on exam. Actually I came back after giving one. It kinda went well.
Also today my dad's bestie who is quite close with doctor actually discussed my dad's case today. And he told us that pelvic mass has reduced quite a bit. This make me wonder do docs see the scans someway differently than radiologists? (What do you think)
Also I think doc worries more about sacral lesion than pelvic one. They have advised against surgery no matter what (I think because of its location at S1). They have advised us to get a PET/CT again 3 months from now. The further treatment will depend on that. If the disease goes stable, then they will do radiotherapy again but if sadly it shows sign of increase then they will start chemo.
Also doc said, doing chemo will be a waste since it will get overshadowed by effect of RT or something similar.

This is all what I have concluded from conversation with my dad.

crybaby
Posts: 18
Joined: Sat Jun 11, 2022 4:20 am

Re: Disease increased after radiation?

Postby crybaby » Wed Jun 22, 2022 4:38 am

Rock_Robster wrote:Sorry to hear the news. Of course it would have been great to see regression of disease across the board. I have two general thoughts here, not sure if very useful:

1. I had been told that a PET within 2 months of surgery or radiation is not particularly useful, due to the high levels of inflammation and post-treatment changes in the tissue. I just had a PET this week 2 months after radiation (and 3 months after surgery), and it was still quite tricky to interpret. Did anyone discuss this aspect with you? Did they also do a diagnostic CT on both scans that could perhaps be used to accurately measure tumor volume (rather than SUVmax activity levels)?

2. If the previous PET was in March and the treatment in May, is it possible that this progression occurred in the period prior to the radiotherapy? So this may in fact not be post-treatment progression, but progression since March and the treatment effects have not yet been seen.

Yes doc have already told us about how it is hard to get a good view from scan post-rad. I think he wanted to get a post-radiation look. I have wrote in my last thread about conversation with doc and how he sees the report. I don't know how I feel about CT scans because we always did them but they never once caught on the disease.
The PET Scan was actually in last week of March and we begin treatment in early April, dad got some complications on last week of treatment so took a break for few days and ended the treatment on 10 May.
I think doc somehow don't think of as a progression though. I will get more details when my dad actually meets doc in coming days.

Thank You


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